7th_DayPac

8/6/2019 7th_DayPac

1/42

8/6/2019 7th_DayPac

2/42

Outlook Brief background history

Objectives of Pre-admission Clinics (PAC)

Who should be seen in PAC

Classification of physical status Patient assessment by organ system

Conclusion

Questions

8/6/2019 7th_DayPac

3/42

Background 1

1992: 6% DOSA (Liverpool Hospital) 6,700 elective admissions

1994: 35% DOSA

2003: 95% DOSA (RMH) > 10,000 elective admissions

8/6/2019 7th_DayPac

4/42

Background 2

Day Case Surgery at Royal Melbourne: Feb. 03 - Jan. 04

2,242 Day cases vs 7,083 Multiday cases

Endoscopies: 2,767 as day cases

5,009 Day cases of a total of 12,092 patients

41 % Day Cases

8/6/2019 7th_DayPac

5/42

Background 3

Mid 90 - PACs everywhere Australia leading the world

Love - hate relationship

Poor guidelines by colleges

Vast differences in organisation and

philosophy

8/6/2019 7th_DayPac

6/42

Objectives 1

Identifying potential anaesthetic difficulties Identifying existing medical conditions

Improving safety by quantifying risk

Allowing planning of peri-operative care

Explain and discuss

Allaying fear and anxiety

8/6/2019 7th_DayPac

7/42

Objectives 2

Reduce costs Increase efficiency of operating time

Increase patient comfort and satisfaction

Reduce cancellations

Reduce FTA

8/6/2019 7th_DayPac

8/42

Classification of Physical Status

AmericanSociety ofAnesthesiologists

ASA

8/6/2019 7th_DayPac

9/42

ASA 1

Class I Normal healthy patient

Class II Mild systemic disease

Class III Severe systemic disease

that limits activity, but is not

incapacitating

8/6/2019 7th_DayPac

10/42

ASA 2

Class IV Severe incapacitating

systemic disease with

constant threat to life

Class V Moribund Patient not

expected to survive 24hours with or without

surgery

8/6/2019 7th_DayPac

11/42

Predictors of operative

morbidity Age

Pre-operative ASA status

Type of surgery (minor vs. major)

Emergency vs. elective

8/6/2019 7th_DayPac

12/42

Day Case Eligibility

Social

medical

facilities and procedures

8/6/2019 7th_DayPac

13/42

Day Case Eligibility 2

Medical Procedure

Minimal bleeding

Minimal pain and nausea

Minimal post op airway compromise

No special nursing requirements

Rapid return to oral intake

8/6/2019 7th_DayPac

14/42

Day Case Eligibility 3

Medical cont. Patients should be fit or well controlled chronic

disease

BMI < 30 (35) Physiological status vs age

Routine rules apply to pre-operative assessment

8/6/2019 7th_DayPac

15/42

Day Case Eligibility:

Ever growing list of procedures: eg: Laparoscopic cholecystectomy

Hernias

VVs Orthopaedics

Plastics

Urology

Eyes

8/6/2019 7th_DayPac

16/42

Who should be seen Type of surgery (cataract vs. hemihepatectomy)

Age (? Over 60/65/70)

ASA III and IV

Language Patient request

Previous anaesthetic problems

Social circumstances (country patients, elderlyetc)

Repeat operations

Possible airway problems

8/6/2019 7th_DayPac

17/42

Who should assess

Anaesthetist vs Liaison nurses

RMH: 94% of all patients are seen by

anaesthetist

Patient questionnaire

Nurse assessment guided by protocols

8/6/2019 7th_DayPac

18/42

Organ systems

CVS

Respiratory

Renal

Hepatic

Haematological

Endocrine

8/6/2019 7th_DayPac

19/42

CVS Risk Factors Hypertension

Diabetes

Family History

Cholesterol

Smoking

Obesity

8/6/2019 7th_DayPac

20/42

Guidelines for Perioperative

Cardiovascular Evaluationfor Noncardiac Surgery

ACC/AHA Task Force

JACC 1996; 27:910-945Circulation 1996; 93:1278-1317

8/6/2019 7th_DayPac

21/42

Cardiac risk stratification for Noncardiac

Surgical ProceduresHigh (Reported cardiac risk often

>5% )

Emergent major operations,particularly in the elderly

Aortic and other major vascular

Peripheral vascular

Anticipated prolonged surgicalprocedures associated with large

fluid shifts and / or blood loss

Intermediate (risk generally

8/6/2019 7th_DayPac

22/42

Clinical Predictors of Increased

Perioperative Cardiovascular Risk (MI,

CHF, Death)Major

Unstable coronary syndromes

Recent MI ( >7 days but 30 days) with evidence of important ischemicrisk by clinical symptoms or noninvasive study

Unstable or severe angina (Canadian Cardiovascular Society Class III

or IV). May include stable angina in patients who are unusually

sedentary. Decompensated congestive heart failure

Significant arrhythmia

High-grade atrioventricular block

Symptomatic ventricular arrhythmias in the presence of underlying

heart disease

Supraventricular arrhythmias with uncontrolled ventricular rate

Severe valvular disease

ACC/AHA Task Force

JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317


8/6/2019 7th_DayPac

23/42


Perioperative Cardiovascular Risk (MI,

CHF, Death)Intermediate

Mild angina pectoris (Canadian Cardiovascular Society Class I or II)

Prior myocardial infarction by history or pathological waves Compensated or prior congestive heart failure

Diabetes mellitus

Minor

Advanced age Abnormal electrocardiogram (LVH, LBBB, ST-T abnormalities)

Rhythm other than sinus(eg. atrial fibrillation)

Low functional capacity (eg. Unable to climb one flight of stairs with a bag of

groceries)

History of stroke

Uncontrolled systemic hypertension

ACC/AHA Task Force


8/6/2019 7th_DayPac

24/42

Estimated Energy Requirements

for Various Activities

1 MET Can you take care of yourself?

Eat, dress, or use the toilet?

Walk indoors around thehouse?

Walk a block or two on level

ground at 2-3 mph or 3.2-4.8

km/h?

4 METs Do light work around the houselike dusting or washing

clothes?

MET = metabolic equivalent

4 METs Climb a flight of stairs or walk up

a hill?Walk on level ground at 4 mph or6.4 km/h?

Run a short distance?

Do heavy work around the houselike scrubbing floors or lifting or

moving heavy objects?Participate in moderaterecreational activities like golf,bowling, dancing, doubles tennis,or throwing a baseball orfootball?

10 METs Participate in strenuous sportslike swimming, singles tennis,

football, baseball, or skiing?

8/6/2019 7th_DayPac

25/42

Stepwise Approach to Preoperative Cardiac

Assessment2. Coronary

revascularization

within 5 years ?

Recurrent

symptoms

or signs ?

Urgent or

Elective

Yes

Yes

No1. Need for

noncardiac

surgery

3. Recent

coronary

evaluation

No

Recent coronary

angiogram or

stress test ?

Postoperative risk

stratification and risk

factor management

Operating

Room

4. Clinical

predictorsEmergency Yes

No

Favorable AND no

change in symptoms

Unfavorable

OR change in

symptoms

ACC/AHA Task Force


8/6/2019 7th_DayPac

26/42


Assessment4. Clinical

predictors

6. Intermediate

clinical

predictor

7. Minor or no

clinical

predictor

5. Major

clinical

predictor

Advanced age

Abnormal ECG

Rhythm other than sinus

Low functional capacity

History of stroke

Uncontrolled systemic

hypertension

Mild angina pectoris

Prior myocardial

infarction

Compensated or prior

CHF

Diabetes mellitus

Unstable coronary

syndromes

Decompensated congestive

heart failure

Significant arrhythmia


ACC/AHA Task Force


8/6/2019 7th_DayPac

27/42


Assessment

5. Major

clinical

predictor

Major Clinical Predictor

Unstable coronary

syndromes

Decompensated congestive

heart failureSignificant arrhythmia


ACC/AHA Task ForceJACC 1996; 27:910-945; Circulation 1996; 93:1278-1317

Consider delay

or cancel

noncardiac surgery

Consider

coronary

angiography

Medical

management and

risk factormodification

Subsequent care

dictated by

findings andtreatment results

8/6/2019 7th_DayPac

28/42


AssessmentFunctionalcapacity

Surgical

risk

Noninvasive

testing

Invasive

testing

6. Intermediate

clinical

predictor

Moderate or

excellent

(>4 METs)

Intermediate

or low surgical

risk procedure

High surgical

risk procedure

Low surgical

risk procedure

8. Noninvasive

testing

Postoperative

risk stratification

and risk factor

reduction

Low risk

High risk

Poor

(

8/6/2019 7th_DayPac

29/42


AssessmentFunctionalcapacity

Surgical

risk

Noninvasive

testing

Invasive

testing

Poor

(4 METs)

Intermediate

or low surgicalrisk procedure

High surgical

risk procedure

Low surgical

risk procedure

8. Noninvasive

testing

Postoperative

risk stratification

and risk factor

reduction

Low risk

High risk

7. Minor or no

clinical

predictor

Consider

coronary

angiography

Operating

room

Subsequent

care dictated

by findings and

treatment results

ACC/AHA Task ForceJACC 1996; 27:910-945; Circulation 1996; 93:1278-1317

8/6/2019 7th_DayPac

30/42

Respiratory 1 Guidelines not as clear

Poor respiratory function increases the

risk of perioperative complications

Respiratory function can often be

optimised

Asthma much better controlled today

8/6/2019 7th_DayPac

31/42

Respiratory 2 Often determines anaesthetic technique

GA vs. regional

Epidural for pain relief

8/6/2019 7th_DayPac

32/42

Respiratory 3 History of asthma/COAD/Malignancy

Exercise tolerance Can you climb 2 flights of stairs?

Drug history Inhalers, nebuliser, steroids

8/6/2019 7th_DayPac

33/42

Respiratory 4 Hospital admissions

Frequent infections

Previous operations

8/6/2019 7th_DayPac

34/42

Respiratory 5 CXR

Respiratory Function Tests

Arterial Blood Gases

Exercise Testing

Occlusive Vascular Tests

8/6/2019 7th_DayPac

35/42

Respiratory 6

Referral to Physician

Optimisation of condition

Steroids

Reschedule

8/6/2019 7th_DayPac

36/42

Diabetes History (Type, how long)

Treatment

How well controlled

Complications (IHD, PVD, Neuropathies,

Renal Impairment,

retinopathy)

8/6/2019 7th_DayPac

37/42

Renal History

Medication

Severity

Dialysis

Crea / Urea

Complications (Hypertension, Anaemia

IHD, fluid overload)

8/6/2019 7th_DayPac

38/42

Hepatic History

Infection / alcohol / drug abuse

LFT / coagulation

Complications (generally poor conditions,

CVS, RS)

8/6/2019 7th_DayPac

39/42

Conclusion Preadmission clinics are here to stay

Essential for economy and patient safety

Systematic approach to patient assessment

Patient assessment in context of surgery Protocols for common situations

Specialised nurses will take lead role in patientsassessment and triage

8/6/2019 7th_DayPac

40/42

Conclusion Team approach needed in assessment

and preparation of the sick patient

8/6/2019 7th_DayPac

41/42

Any Questions?

8/6/2019 7th_DayPac

42/42

Documents

7th_DayPac